MEDICARE: MISS TRACY MARIE LEWIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0006994	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093947657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TRACY MARIE LEWIS LCSW

Provider Business Mailing Address
First Line	:	925 SULLIVAN AVE
Second Line	:	UNIT 2
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2025
Country	:	US
Telephone Number	:	860-432-7771
Fax Number	:	860-432-7774

Provider Business Practice Location Address
First Line	:	925 SULLIVAN AVE
Second Line	:	UNIT 2
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2025
Country	:	US
Telephone Number	:	860-432-7771
Fax Number	:	860-432-7774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2009
Last Update Date	:	07/01/2015

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